Sean Johnson keeps a pack of Marlboro Reds in a satchel slung across his right shoulder. He tried his first cigarette when he was 11 years old, and started smoking “officially” when he was 17 — around the same time that he was diagnosed with schizoaffective disorder. Now 45, Sean is one of millions of people with mental illness who are addicted to cigarettes. “It’s been several times I wanted to quit, but I never got around to it,” he told me.

Almost 46 million adults in the U.S. have a mental illness, and according to a report released by the Centers for Disease Control last month, about 36 percent of them smoke — a rate 70 percent higher than people without mental illness. People with mental illness also die 25 years earlier on average than the general population, most frequently due to smoking related illnesses like heart disease and emphysema. Researchers are torn on the exact relationship between smoking and mental illness, but they agree that the barriers to quitting are considerable, supported by the culture of smoking and the tobacco industry itself.

Most people with mental illness who are addicted to cigarettes started smoking when they were young. There is an ongoing debate over which comes first — cigarette smoking or the symptoms of mental illness — but both tend to manifest in adolescence and early adulthood. Some researchers suggest that smoking can cause mental illness, but most believe that the relationship is cyclical. In the U.S., the stressful conditions that encourage smoking — such as low-education and low-income levels — also breed poor mental health. And once a person with mental illness starts smoking, those stressors are amplified by the torment of addiction and withdrawal.

“When I wake up in the morning, I have to wonder ‘Is this going to be a bipolar day?’” one woman told a researcher in excerpts from focus group interviews published in the journal Health and Social Work. Many of those interviewed reflected that quitting smoking while trying to maintain their daily stability would be overwhelming, and referred to smoking as a form of stress relief.

“A lot of patients will tell you that smoking helps calm them down, reduces their anxiety, and were they to get their anxiety treated in other ways they might be able to cut down on their smoking,” said Karen Lasser, a primary care physician and researcher at Boston University School of Medicine.

There is some evidence backing that perception. Nicotine binds to receptors in the brain that trigger the release of acetylcholine — a neurotransmitter that increases arousal and attention. Acetylcholine also stimulates the neurotransmitters dopamine (which is involved in feelings of reward) and glutamate (which enhances learning and memory).

Research suggests that smoking might work to ease the negative moods characteristic of both depression and anxiety by increasing the activity at dopamine receptors in the brain. And in many mental disorders, the brain’s ability to filter out excess stimuli is impaired, a trait that is particularly true of schizophrenia. Some studies have shown that nicotine helps people with mental illness focus and process information more coherently.

The relationship between smoking and mental illness is not so straightforward, however, according to a 2008 report from the National Institutes of Health. Smoking can alleviate stress, the report explains, but it is hard to tell whether that stress is due to mental illness or addiction — or both.

When a person’s anxiety abates after they smoke a cigarette, the nicotine is treating the symptoms of withdrawal rather than the underlying condition, said Douglas Ziedonis, chair of the psychiatry department at University of Massachusetts Medical School. People with mental illness who have never smoked don’t experience the same relief.

And while poor mental health has been found to lead to cigarette smoking, smoking does not result in improvements in mental health. In fact, the stress of addiction may even worsen some of the symptoms of mental illness. “If these behaviors are being used as a coping mechanism, our research suggests that they are not very effective,” Jennifer Walsh, a researcher at the Centers for Behavioral Health and Preventive Medicine in Rhode Island, wrote in an email.

Thirty years ago, mental health facilities encouraged patients to smoke by handing out cigarettes as a reward for good behavior. Many healthcare providers still believe that depriving a smoker with mental illness of cigarettes will increase their risk of relapse for other substances or worsen their psychiatric symptoms, though both ideas have been debunked by recent research.

“Longer term studies where people with serious mental illness have quit smoking don’t show that they have worse outcomes from their mental health problems,” Zeidonis said. “That they were able to be successful at quitting might be something that really helps their self-confidence.” And even if smoking were a form of “self-medication,” continued Ziedonis, its harmful long-term health effects far outweigh any short-term benefits.

The recent CDC report may have increased public awareness of tobacco consumption among people with mental illness, but the problem is far from new. “For a long time psychiatrists noticed smoking behaviors in their patients, but that was just sort of who they were,” said Laura Hirshbein, a psychiatrist at the University of Michigan. “It took a while for anyone to really comment much on smoking and mental illness even though it was incredibly common and everybody really knew about it.”

In the 1950s and 60s, before many psychologists and psychiatrists questioned their patients’ cigarette intake, the tobacco industry was interested in exploring the link between smoking and mental illness. Some of the earliest breakthroughs in our understanding of the effects of nicotine on the brain came from tobacco industry funded research. In addition to providing researchers with grant money, the industry sponsored conferences and cultivated relationships with psychiatrists who were receptive to the idea of cigarettes as “self-medication” for mental illness.

Cigarette companies used the research on smoking and mental illness to design advertisements promoting cigarettes as effective methods of stress relief. They also encouraged the smoking habits of people with mental illness in other ways: Up until the 1980s tobacco companies would mail free samples to people in psychiatric facilities and often sent “charitable donations” to schizophrenia associations in their states, according to Hirshbein.

But as public opinion turned against the tobacco industry in the 1990s, psychologists became more interested in treating tobacco addiction in their patients. Mental hospitals began to go smoke-free, and in 1994 the Diagnostic and Statistical Manual was revised to include the category of nicotine dependence.

“The switch toward seeing smoking cessation for mentally ill patients has only happened in the last 15 years or so,” Hirshbein said.

The rate of smoking among people with mental illness has dropped over time, though not as dramatically as the smoking rate in the general population has. To explain the discrepancy, Ziedonis and others argue that smokers with mental illness were simply less responsive to the changing cultural forces that precipitated the general decline of tobacco use in the U.S. Meanwhile, in China, where anti-smoking sentiment is not as strong as it is in the states, people with schizophrenia smoke at the same rate as the general population, Ziedonis said.

In a 2011 Dartmouth study examining the patterns of smoking behavior in people with mental illness in the U.S., the participants who never smoked tended to be younger. The finding is similar to the trend in the general population, and suggests that while smoking and mental illness are not inextricably linked, people with mental illness may have a harder time quitting once they become addicted.

Research has shown that people with mental illness want to quit, and can, but that they need extra help along the way. In the Dartmouth study, most participants attempted to quit multiple times, unsuccessfully. Some researchers propose that people with mental illness have a comparatively lower tolerance for stress, making it harder to cope with withdrawal. Others have suggested that withdrawal itself could be worse in people with mental illness.

Without expanding access to care and reducing the cost of smoking interventions, however, cigarettes will still be more appealing than the alternative.

“I recently had a patient who I was trying to prescribe nicotine replacement therapy and his insurance didn’t cover it, and it’s awfully expensive and he couldn’t afford the co-pays for the medication,” Lasser said. “I think we need to reduce the cost barrier to people getting treatment.”

One way to increase treatment availability, according to Ziedonis, is to integrate stop-smoking interventions into general care for mental illness. “In primary care we really see smoking cessation as our bread and butter,” Lasser said. But most people with severe mental illness are treated in the mental health system, where stop-smoking programs are only beginning to gain traction.

“It’s a cultural shift of both role and what you would put on the treatment plan,” Ziedonis said. “We can see now that people are more motivated than mental health clinicians initially thought. When you open the door, people want to go through it.”

Since he started smoking, the longest amount of time Sean Johnson has gone without cigarettes is two to three weeks. “The craving got to me,” he told me. “I miss the feeling that it gives me when I smoke, the feeling I get in my head.” Still, he has managed to cut back to between 12 and 16 cigarettes a day, down from a pack. He participates in a counseling program for tobacco addiction at the Mental Health Association of New York City (MHA-NYC).

“I think it has helped people move from ambivalence to thinking more seriously and really wanting to quit,” said Elizabeth Hyde, director of Harlem Bay Network PROS, which runs the stop-smoking program at MHA-NYC. “It’s being able to [quit] that people are getting stuck at.” The smoking cessation program launched only last year, but for the first time the most recent session was entirely full.

In the elevator after our interview I ran into Sean again, cigarette in hand. He lit up while still in the building lobby as he wished me luck on the article. Despite the obstacles, he said he is still interested in quitting.

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